Provider Demographics
NPI:1740288034
Name:WILSON, BRIAN L (DMD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:L
Last Name:WILSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2350 NW CENTURY DR
Mailing Address - Street 2:STE #200
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-3495
Mailing Address - Country:US
Mailing Address - Phone:541-768-0419
Mailing Address - Fax:541-768-0521
Practice Address - Street 1:2350 NW CENTURY DR
Practice Address - Street 2:STE #200
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3495
Practice Address - Country:US
Practice Address - Phone:541-768-0419
Practice Address - Fax:541-768-0521
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-11
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD78431223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics